Liver Transplant


Donor Issues/ Criteria

  1. Longer cold ischemia assoc w/complications & graft dysfxn
  2. Donor presence of antibodies to CMV is not contraindication but increases risk for reactivitation of CMV in recipient
  3. Left or right hemiliver grafts from living related donors

Recipient Issues/Criteria

  1. Graded on Child-Turcotte-Pugh (CTP) classification
  2. Survival rates: >85% at 1yr, >70% at 5yrs
  3. Indications for transplant
  4. Contraindications for transplant
  5. Pretransplant evaluation

Bridge to Liver Transplantation

  1. Exchange transfusions, steroids, hemodialysis, & charcoal hemoperfusion have been tried in setting of acute liver failure
  2. Three systems are currently being studied to provide metabolic & excretory fxn of liver

Post-Operative Issues

  1. Hepatic fxn can be determined by the following signs postop:
  2. Immunosuppression started w/CsA or tacrolimus & steroids; third agent sometimes used as azathioprine or MMF
  3. If T-tube is used, it should be clamped postop day 5 if no complications found

ID Prevention

  1. Immunization: Hep B, pneumcoccal vaccines & yearly Influenza A vaccines should be given; avoid live vaccines
  2. Prophylaxis:


Emergency Presentations - Infections

Hyperacute Rejection

  • Preformed Ab bind to Ag & Activate complement system, platelet aggregation, & microvascular obstruction
  • Incidence is low due to crossmatch of ABO and HLA
  • Rejection may occur w/in minutes of revascularization & during operation or hrs later
  • Process is irreversible

Acute Rejection

Diagnosis

  • Sx of liver failure:
    • fever, malaise, anorexia, RUQ/abd pain, ascites, decr bile output, incr bilirubin &/or transaminases
  • DDx includes: (use doppler U/S & liver Bx)
    • Primary graft nonfxn, preservation injury
    • Vascular thrombosis
    • Biliary anastomotic leaks or stenosis

Pathophysiology

  • Caused by T- and B-lymphocytes, which attack microvasculature & impair graft perfusion
  • At least 60% have 1 episode w/in first 3mos (often in first 2wks)
  • Process occurs usually < 3mo posttransplant & is reversible
  • Late allograft dysfunction can be due to rejection, Hep B or C, CMV, EBV, cholestasis, or drug toxicity
  • Late acute rejection occurs >6mos & often assoc w/withdrawal of immunosuppression

Treatment

  1. Tx w/pulse methylprednisolone 500-1000mg IV or high-dose prednisone (60-80% response rate); more severe rejection TX w/antilymphocyte AB
  2. Avoid blood transfusions

 

Chronic Rejection

  • More insidious Sx >1yr from transplant
  • Dx is difficult & usually done w/biopsy
  • No effective therapy available

 

Long-Term Complications

  • Severe dysfunction or primary non-function of allograft may require re-transplantation
    • Trend in transaminases should be downward & should be w/u further if cont to rise beyond 12-24hr post-op
  • Tx of severe hepatic dysfunction is supportive w/IV PGE1 shown to be beneficial
  • Bioartificialliver can be used to allow liver to recover or as bridge to new transplant
  • Biliary leaks cause localized or generalized peritonitis; Tx by ERCP or return to OR
  • Recurrence of native Dz can occur, most common ID in nature like Hep B and C, but also primary biliary cirrhosis, primary sclerosing chonangitis; both Dx w/biopsy
  • Hepatocellular CA poor prognosis